Basic Information
| Provider Information | |||||||||
| NPI: | 1962644021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | MIRTHA | ||||||||
| MiddleName: | AMELIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6227 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TAMARAC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333214022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545291075 | ||||||||
| FaxNumber: | 9547216308 | ||||||||
| Practice Location | |||||||||
| Address1: | 6227 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TAMARAC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333214022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545291075 | ||||||||
| FaxNumber: | 9547216308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | DO2462 | FL | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.